Doctors care but do they share?

A CHAMPION of evidence-based medicine warns Australia is “drastically lagging behind” other countries in equipping patients with the information they need to share in decision making.

Professor Chris Del Mar, professor of public health at the Centre for Research in Evidence-Based Practice at Bond University, Queensland, said much more needed to be done to help doctors adopt shared decision making techniques, which include educating patients on medical evidence and guiding them to make their own decisions about screening, tests and treatments.

“Gone are the days where the profession holds all of the information and the doctor knows best”, he said.

“The job of the doctor now is to clearly present the evidence and the options to the patient. It’s about making sure you know the options and communicate them clearly.”

Professor Del Mar is a coauthor of a “Clinical focus” article in the MJA today which presents a case for why shared decision making is important in practice. (1)

The authors argued that shared decision making could reduce the inappropriate use of tests and treatments, as patients typically opted for more conservative options than doctors.

They also cited evidence to refute some of the myths of shared decision making, including that it made consultations longer, and was not appropriate for people with low health literacy.

Professor Del Mar told MJA InSight doctors needed training in the shared decision making process, but that once learned it was relatively straightforward to implement. Doctors are encouraged to discuss with patients what would happen if they “waited and watched”, and to discuss the benefits and harms of each treatment option, acknowledging that different patients have different preferences.

Even when patients wanted to “abdicate” their responsibility by asking the doctor “what would you do?”, Professor Del Mar said a good doctor would acknowledge that “what I would do is because of who I am, and not everybody’s the same”.

While shared decision making is a cornerstone of America’s Obamacare health plan and at the centre of public health campaigns in the UK, Professor Del Mar said the concept has less traction in Australia.

He cited one example where he had approached Medical Deans Australia and New Zealand to take part in a conference on shared decision making, but they did not attend.

“Shared-decision making needs to be on the agenda at medical schools and colleges. It needs to be being taught to medical students, medical professionals and patients.”

Medical Deans Australia and New Zealand did not say why they declined Professor Del Mar’s invitation. However, CEO Professor Judith Searle told MJA InSight the deans supported a patient-centred approach to health care, the strengthening of relationships between doctors and patients, and the production of “quality medical graduates with excellent communication skills”.

Consumers Health Forum of Australia CEO Adam Stankevicius agreed that Australian clinicians could often do more to involve patients in decisions about their care. However, he said this was “not a problem peculiar to Australia”

He cited the findings of the latest report from The Commonwealth Fund of New York comparing 11 national health systems, which showed Australia scraped into the top half of rankings on “patient-centred care measures”. (2)

Mr Stankevicius applauded the work of Sydney’s Clinical Excellence Commission and the Victorian Health Issues Centre to promote better decision sharing and engagement between clinicians and patients.

Dr Karen Luxford, director of patient-based care at the Clinical Excellence Commission, said a common problem was “patient preference misdiagnosis”. For example, in one study, doctors believed that 71% of patients with breast cancer would rate keeping their breast as a top priority, even though only 7% of patients rated this as their top priority. (3)

“True shared decision making requires an understanding of the patient’s goals and expectations — this is something we don’t always do so well in health care”, she said.

‘Sharing is caring’ and it’s time we do more of it, thanks for a great article. The big obstacles of course are time and profit – it takes time to explain and that time could be spent seeing other patients… If we are serious about patient centredness we need to allocate the time it takes and stop putting economists in hospital management.

What is being referred as Shared decision making is really “informed consent”. The general mistake made and probably appertaining to all the research related to the question of “shared decision making” is to include input which involves any other health professionals or opinion makers, or a favourite term used by non-clinical interested parties or bureaucrats, Boards etc, includes “stakeholders”. Any such decision, which includes “stakeholders”, is against the whole tenet of the doctor-patient relationship and informed consent, as in addition to being a third party is third party-centred, not patient centred. Given the patient has / had capacity to make decisions, renders any third party opinion unethical, in my view and according to Human Rights, values based decision making and ethical standards of medical practice. The term “shared decisions” is an unfortunate one. “Co-decision” would be better, “informed decision making” obviously even better in terms of defining patient goals and “happiness” as the goal standard of outcome, not only of patient-centred care, but care involving the active participation of the patient i.e. patient-health care. Not only is this shared, but depends on mutual trust. Was trust as the basis of the doctor-patient relationship and “patient happiness” either in terms of medical outcome and residence or return to work as a goal used as the outcome measure in Prof Del Mar’s or others’ work?

Co-decision making is a great ideal. I fully support it and practice it frequently. However, every time I do so, I am painfully aware of the cost to my income. The additional time spent with the patient (when compared with coming to a decision for them, with far less of their involvement) turns a 9 or 10 minute consultation into a 16 or 17 minute one, at the very least. Do that 10 times a day and I’ve suddenly lost 70 minutes. This can be seen as, at the very least, seven fewer standard consultations or approximately $260 less per day, $1300 less per week, $63,000 less per year. For practicing good medicine! Of course I could get smart and stretch the consult to 20 minutes, lose only about $200 per week or $9,600 per year. I could even decide, as my reputation grew, to charge the full AMA fee for half my (full fee-paying) patients and INCREASE my income by $950 per day, $4750 per week, over $200,000 per year. Those patients who can “afford to pay” would bear the cost. Finally, I could get a salaried job and in the long run the taxpayer would cough up, as my efficiency per consult inevitably decreased. The common theme here, is that not one of the options DECREASES the cost of the shared decision option. Somewhere, someone bears the cost. Helping people to live longer has never been proven to decrease costs either – it just shifts them further down the line. Who is able to wisely help US as doctors, make the right decision regarding which course to take?

Dr Myer, it is unclear what entity you consider is the unwelcome third party in your objection. I wonder if you are confusing the terms Shared Decision Making (SDM) and Managed Care. SDM has nothing to do with bureaucrats or Boards making decisions; it is a method to help the doctor provide balanced evidence for and against a proposed treatment, and by discussing these, the patient has the opportunity to flag their preferences—an opportunity which may be missed if the doctor merely informs the patient that ‘I think treatment X is best for you.’ As you say, SDM enhances the concept of informed consent, which I assume you agree is a good thing?

As for TB’s financial objections, it is true that, at least at the initial consultation, SDM may take a little more time –although I can’t imagine anyone using it to extend 10 consultations a day. But its occasional use is likely to save time in the long run, to reduce inappropriate tests or treatments, and to 7386improve patient outcomes and satisfaction with the consultation. Isn’t that why we work in this game? If a useful communication tool prolongs the odd consultation, so be it. The same could be said of patient handouts, diagrams and decent explanations of management. These things also reduce waste, angst, litigation and overtreatment—all of which have their own expenses. And with any luck, they might actually improve the outcomes Dr Myer rightly values – happiness and trust.

It is basically informed consent, on steroids maybe, and many if not most of us have been doing it for years. However, TB’s comments re what it costs – us, that is – in terms of time added on but not adequately paid for is an issue which is not going to go away as we are expected to deal more and more with chronic disease. For this reason alone – and there are many others – it is just time that the whole method of GP remuneration needs to be addressed, and it is no coincidence, that people like Prof Del Mar, who is raising this isue are often salaried academics who are not forced to face the realities of the usual GP world we now have to practice within.

I am quite fine with shared decision making as long as responsibility is to be equally shared. Bit like the administrators who daily tell us what we can and can’t do, or skulk around looking for excuses to harass, then sheet the blame for any slip or incident onto the coal face worker. All authority and no responsibility.

As somebody who has tried to get patients to “share” responsibility via decision making and sensible advice, I know it to be an often thankless task. All too often the time is not available and too many others have got in before you, for advice to be received effectively.. “How do you know you are allergic to X, Y or Z?” “The nurse told me I could have died”, “Did you go to Intensive care?” “No”, “Were you tested by a Specialist?” “No”, “So why do you say you are allergic?” “The nurse told me” “But I have just explained, years of training experience (30 years an anaesthetist) suggest that you are not.” “But the nurse said I was”.. Repeat ad-nauseam any number of times.

There is also the problem of patients “owning” their condition, whatever TF that means. “Oh, but I want to be in control!!” “Of what?” “Going to sleep” “Like when you sleep at night?” “No, that’s different, isn’t it?” “Or driving a car, with all those other people driving at random around and towards you? Are you in control then?” “Oh..”

There appears to me to be a lack of evidence for some of the statements in the above article, including that doctors need training in shared decision-making , and that the latter could reduce inappropriate tests and treatments.

What doctors and students and others need is ongoing training in informed consent, which includes medico-legal , ethical, and human rights issues.

This should not be confused with cost-benefit anaylsis training regarding decisions ( with informed consent ) to treat /investigate/refer or not to do so – a financial issue, relevant to informed consent if the patient has to pay .

What concerns me about the MJA article , is the lack of advice to the parent of the child with otitis media with a history of fever on what to do if the watch and wait approach fails, or antibiotic treatment fails ,and the child gets worse-see fact sheets on the septic child who also happens to have a red tympanic membrane.